The tendency of a material to break under repeated stress. Nine A.M. after a long 12-hour overnight shift in the Emergency Department, I sit in front of my computer and stop to wonder if it’s possible for me to break under repeated stress. We hear stories of this or that ER doc who cracked under pressure and quit the field or the other ER doc who had a nervous breakdown in the ambulance bay. Eventually you start to wonder exactly how much repeated stress that might take.

We build walls, you know. The general public might lay on the criticism, but without the walls we’d be totally defenseless and out of the job. We start laying down the bricks in medical school and go on building them thicker and thicker as the years go on. I’ve known some people who even pour metaphorical cement on top, just to be extra safe. Walls protect us from the collateral emotional damage that can come from absorbing the pain and suffering of our patients. Walls allow us to go on with our shift, to take care of that next patient, to go home and say, “Fine” when asked about our day, to be a normal person when with our friends and family.

There’s a thing out there called compassion fatigue. I think about that a lot. It’s like that weird nauseated feeling you get when you have to reassure someone that his badly head-injured 32-year-old brother still stands a fighting chance of some neurologic recovery. It makes us weary, cranky, and, depressed. It makes us reach for doughnuts in the middle of the night. Compassion fatigue also has a bad tendency to invite cynicism and hopelessness to join us at the bedside and that’s never a fun time for anyone. So I think we build our walls thick because we worry that they might fatigue and crack under the weight of too much compassion. Because then we’d be totally helpless.

Last night I took care of a young woman with lupus who had just started dialysis and wasn’t doing well. Her mother had brought her in for difficulty breathing in the middle of the night. I walked into the room and her mother immediately took over the conversation. There was something terribly wrong with her daughter. Why wasn’t she getting better? Why did the doctors ignore her like nothing was wrong? Her volume quickly ramped up to LOUD and she alternated between waving her hands around her head and covering her face with them as she yelled in the space around me. She also yelled at me. I didn’t say anything. I could see the panic in her eyes. She was afraid she was going to lose her daughter.

Just then another patient of mine — a lovely, sharp-tongued, elderly man — went into cardiac arrest and died.

And right before shift change, the paramedics brought in a bleeding, unconscious mother who had gotten hit by a car in front of her two small children. Her sobbing husband stood in the hallway behind the stretcher, waiting for me to tell him if his wife was going to make it or not.

When I was done, I signed off to the morning team, put on my coat, and went home like a normal person.

So I’m tired. Fatigued, really. It’s been a long night and I’m still awake, staring at my computer, mug of coffee clutched in a death grip in both hands. Morning sunlight pours through a slit in my blackout shades. I’m not sure what kind of condition my walls are in and quite frankly I’d rather not know at this particular moment. I think to myself that this is madness to be awake for the sole purpose of stirring up my feelings attached to the events of the night. Sadness, frustration, anger, hopelessness. I should have just gone to bed. I wonder if I’m only making it harder for myself to wake up for the next shift in a few hours. Maybe these feelings are inviting burnout, compassion fatigue, exhaustion, and cynicism.